nursing home in Rockford, IL

Pa Peterson at the Citadel

1311 Parkview Avenue, Rockford, IL 61107 · (815) 399-8832

★★★★★1
Much below average
CMS overall star rating
  • Health inspections★★★★★2
  • Staffing★★★★★1
  • Quality measures★★★★★4
  • Abuse citation

Source: Centers for Medicare & Medicaid Services (CMS), Medicare Care Compare. We refresh our information from this source. About our data

Pa Peterson at the Citadel at a glance

Pa Peterson at the Citadel is a 129-bed for-profit nursing home in Rockford, Illinois (Winnebago County).

CMS gives it 1 out of 5 stars on its overall star rating, worse than the Illinois average of 2.5.

Residents receive about 3.7 hours of nursing care per day (0.6 of them from registered nurses), better than the state average of 3.4 hours.

Its most recent standard health inspection (May 21, 2025) found 19 health citations. The Illinois average is 12.5.

Federal regulators fined it 1 time in the past three years, totaling $21,212.

Nursing staff turnover is 59.6% per year (state average 44.5%).

Facility details

Type
Nursing home
Ownership
For Profit - Partnership
Beds
129
Certified for
Medicare and Medicaid
Chain / affiliated entity
Citadel Healthcare
Medicare-certified since
September 1, 1993
Continuing care retirement community
Yes
Resident/family council
Resident
County
Winnebago County
CMS Certification Number
145751

Ratings

MeasureThis facilityIllinois avg.U.S. avg.vs. U.S.
Overall star rating ⓘ (higher is better)1 / 52.5 / 53 / 5Worse
Health inspection rating ⓘ (higher is better)2 / 52.7 / 52.8 / 5Worse
Staffing rating ⓘ (higher is better)1 / 52.1 / 52.9 / 5Worse
Quality measures rating ⓘ (higher is better)4 / 53 / 53.6 / 5Average
Long-stay quality rating (higher is better)4 / 53.4 / 53.8 / 5Average
Short-stay (rehab) quality rating (higher is better)4 / 52.5 / 53.3 / 5Better

Staffing

This facility3.70 hrsIllinois average3.45 hrsU.S. average3.86 hrs
Total nurse staff hours per resident per day: this facility vs. Illinois and U.S. averages
MeasureThis facilityIllinois avg.U.S. avg.vs. U.S.
Total nurse staff hours per resident per day ⓘ (higher is better)3.70 hrs3.45 hrs3.86 hrsAverage
Registered nurse hours per resident per day (higher is better)0.62 hrs0.72 hrs0.69 hrsWorse
Nurse aide hours per resident per day (higher is better)2.23 hrs2.09 hrs2.32 hrsAverage
Weekend nurse staff hours per resident per day (higher is better)3.47 hrs3.07 hrs3.42 hrsAverage
Nursing staff turnover (yearly) (lower is better)59.6%44.5%45.8%Worse
Registered nurse turnover (yearly) (lower is better)53.8%41.8%42.9%Worse
Administrators who left in the past year (lower is better)001Better

Inspections

This facility19Illinois average12U.S. average9
Health citations in the most recent inspection: this facility vs. Illinois and U.S. averages
MeasureThis facilityIllinois avg.U.S. avg.vs. U.S.
Health citations in the most recent inspection (lower is better)19129Worse
Citations from complaint investigations (latest cycle) (lower is better)753Worse
Weighted health inspection score ⓘ (lower is better)12714380.6Worse

Penalties

This facility1Illinois average2U.S. average1
Fines in the past 3 years: this facility vs. Illinois and U.S. averages
MeasureThis facilityIllinois avg.U.S. avg.vs. U.S.
Fines in the past 3 years (lower is better)121Worse
Total fines in the past 3 years (lower is better)$21,212$111,013$30,972Better
All federal penalties in the past 3 years (lower is better)131Average

Size

MeasureThis facilityIllinois avg.U.S. avg.vs. U.S.
Certified beds129128107
Average residents per day1209586
Occupancy92.7%75%80.9%

Long-stay residents

This facility2.7%Illinois average3.1%U.S. average3.2%
Long-stay residents with a fall causing major injury: this facility vs. Illinois and U.S. averages
MeasureThis facilityIllinois avg.U.S. avg.vs. U.S.
Long-stay residents with a fall causing major injury (lower is better)2.7%3.1%3.2%Better
Long-stay residents with pressure ulcers (lower is better)7.7%4.8%4.6%Worse
Long-stay residents given antipsychotic medication (lower is better)31%21.7%15.4%Worse
Long-stay residents with a urinary tract infection (lower is better)0.6%1.5%1.6%Better
Long-stay residents with a catheter left in the bladder (lower is better)0.5%0.9%0.8%Better
Long-stay residents needing more help with daily activities (lower is better)12.7%13.4%13.9%Better
Long-stay residents whose walking worsened (lower is better)19.1%14.3%14.1%Worse
Long-stay residents who lose too much weight (lower is better)11.7%6.3%5.2%Worse
Long-stay residents with depressive symptoms (lower is better)93.7%54.2%12.8%Worse
Long-stay residents who were physically restrained (lower is better)0%0.1%0.1%Better
Long-stay residents given anti-anxiety or sleep medication (lower is better)14.2%18.3%19.5%Better
Long-stay residents with new or worse incontinence (lower is better)20.9%20.6%19%Worse
Long-stay residents given a flu vaccine (higher is better)62.1%91.8%95.5%Worse
Long-stay residents given a pneumonia vaccine (higher is better)91.3%90.3%93.6%Average

Short-stay residents

This facility1.6%Illinois average2.2%U.S. average1.6%
Short-stay residents newly given antipsychotic medication: this facility vs. Illinois and U.S. averages
MeasureThis facilityIllinois avg.U.S. avg.vs. U.S.
Short-stay residents newly given antipsychotic medication (lower is better)1.6%2.2%1.6%Worse
Short-stay residents given a flu vaccine (higher is better)31.6%63.1%79.8%Worse
Short-stay residents given a pneumonia vaccine (higher is better)78.5%69.7%82%Average

Inspection citations

State inspectors cited this home for 65 health deficiencies and 3 fire safety deficiencies in the inspection records CMS currently publishes. 3 citations involved actual harm.

DateCitationSeverityStatus
July 7, 2026
Complaint
Protect each resident from the wrongful use of the resident's belongings or money.
Freedom from Abuse, Neglect, and Exploitation Deficiencies · Tag F0602
D
Potential harm, isolated
Corrected July 10, 2026
June 25, 2026
Complaint
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Quality of Life and Care Deficiencies · Tag F0686
D
Potential harm, isolated
Corrected July 2, 2026
June 25, 2026
Complaint
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Freedom from Abuse, Neglect, and Exploitation Deficiencies · Tag F0600
D
Potential harm, isolated
Corrected July 2, 2026
April 3, 2026
Complaint
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies · Tag F0689
D
Potential harm, isolated
Corrected April 8, 2026
March 2, 2026
Complaint
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Quality of Life and Care Deficiencies · Tag F0686
D
Potential harm, isolated
Corrected March 5, 2026
December 2, 2025
Complaint
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Pharmacy Service Deficiencies · Tag F0755
D
Potential harm, isolated
Corrected December 5, 2025
November 24, 2025
Complaint
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies · Tag F0689
D
Potential harm, isolated
Corrected December 4, 2025
May 21, 2025
Standard
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Nursing and Physician Services Deficiencies · Tag F0725
E
Potential harm, pattern
Corrected May 30, 2025
May 21, 2025
Standard
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Quality of Life and Care Deficiencies · Tag F0684
E
Potential harm, pattern
Corrected May 30, 2025
May 21, 2025
Standard
Provide and implement an infection prevention and control program.
Infection Control Deficiencies · Tag F0880
E
Potential harm, pattern
Corrected May 30, 2025
May 21, 2025
Standard
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies · Tag F0689
D
Potential harm, isolated
Corrected May 30, 2025
May 21, 2025
Standard
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Infection Control Deficiencies · Tag F0883
D
Potential harm, isolated
Corrected May 30, 2025
May 21, 2025
Standard
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Pharmacy Service Deficiencies · Tag F0761
D
Potential harm, isolated
Corrected May 30, 2025
May 21, 2025
Standard
Provide safe and appropriate respiratory care for a resident when needed.
Quality of Life and Care Deficiencies · Tag F0695
D
Potential harm, isolated
Corrected May 30, 2025
May 21, 2025
Standard
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Quality of Life and Care Deficiencies · Tag F0688
D
Potential harm, isolated
Corrected May 30, 2025
May 21, 2025
Standard
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Quality of Life and Care Deficiencies · Tag F0686
D
Potential harm, isolated
Corrected May 30, 2025
May 21, 2025
Complaint
Respond appropriately to all alleged violations.
Freedom from Abuse, Neglect, and Exploitation Deficiencies · Tag F0610
D
Potential harm, isolated
Corrected May 30, 2025
May 21, 2025
Standard
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Freedom from Abuse, Neglect, and Exploitation Deficiencies · Tag F0605
D
Potential harm, isolated
Corrected May 30, 2025
May 21, 2025
Standard
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Resident Rights Deficiencies · Tag F0550
D
Potential harm, isolated
Corrected May 30, 2025
May 21, 2025
Standard
Provide care and assistance to perform activities of daily living for any resident who is unable.
Quality of Life and Care Deficiencies · Tag F0677
D
Potential harm, isolated
Corrected May 30, 2025
December 13, 2024
Complaint
Provide care and assistance to perform activities of daily living for any resident who is unable.
Quality of Life and Care Deficiencies · Tag F0677
D
Potential harm, isolated
Corrected December 19, 2024
December 10, 2024
Complaint
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Resident Rights Deficiencies · Tag F0584
D
Potential harm, isolated
Corrected December 17, 2024
November 19, 2024
Complaint
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Pharmacy Service Deficiencies · Tag F0755
E
Potential harm, pattern
Corrected November 29, 2024
November 19, 2024
Complaint
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Freedom from Abuse, Neglect, and Exploitation Deficiencies · Tag F0609
D
Potential harm, isolated
Corrected November 29, 2024
November 19, 2024
Complaint
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Pharmacy Service Deficiencies · Tag F0761
D
Potential harm, isolated
Corrected November 29, 2024
November 19, 2024
Complaint
Respond appropriately to all alleged violations.
Freedom from Abuse, Neglect, and Exploitation Deficiencies · Tag F0610
D
Potential harm, isolated
Corrected November 29, 2024
November 19, 2024
Complaint
Protect each resident from the wrongful use of the resident's belongings or money.
Freedom from Abuse, Neglect, and Exploitation Deficiencies · Tag F0602
D
Potential harm, isolated
Corrected November 29, 2024
October 18, 2024
Complaint
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Freedom from Abuse, Neglect, and Exploitation Deficiencies · Tag F0607
D
Potential harm, isolated
Corrected October 29, 2024
October 18, 2024
Complaint
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Freedom from Abuse, Neglect, and Exploitation Deficiencies · Tag F0609
D
Potential harm, isolated
Corrected October 29, 2024
October 16, 2024
Complaint
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Resident Rights Deficiencies · Tag F0580
D
Potential harm, isolated
Corrected October 29, 2024
October 7, 2024
Complaint
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Quality of Life and Care Deficiencies · Tag F0684
D
Potential harm, isolated
Corrected October 29, 2024
October 7, 2024
Complaint
Provide enough food/fluids to maintain a resident's health.
Quality of Life and Care Deficiencies · Tag F0692
D
Potential harm, isolated
Corrected October 29, 2024
September 24, 2024
Complaint
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Pharmacy Service Deficiencies · Tag F0755
D
Potential harm, isolated
Corrected October 7, 2024
September 12, 2024
Complaint
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Pharmacy Service Deficiencies · Tag F0755
D
Potential harm, isolated
Corrected September 18, 2024
September 12, 2024
Complaint
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Quality of Life and Care Deficiencies · Tag F0684
D
Potential harm, isolated
Corrected September 18, 2024
September 12, 2024
Complaint
Provide safe and appropriate respiratory care for a resident when needed.
Quality of Life and Care Deficiencies · Tag F0695
D
Potential harm, isolated
Corrected September 18, 2024
August 30, 2024
Complaint
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Quality of Life and Care Deficiencies · Tag F0744
D
Potential harm, isolated
Corrected September 10, 2024
August 20, 2024
Complaint
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Quality of Life and Care Deficiencies · Tag F0684
D
Potential harm, isolated
Corrected September 4, 2024
July 18, 2024
Complaint
Provide and implement an infection prevention and control program.
Infection Control Deficiencies · Tag F0880
E
Potential harm, pattern
Corrected July 29, 2024
July 10, 2024
Fire safety
Address subsistence needs for staff and patients.
Emergency Preparedness Deficiencies · Tag E0015
F
Potential harm, widespread
Corrected August 23, 2024
July 10, 2024
Standard
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Quality of Life and Care Deficiencies · Tag F0684
G
Actual harm, isolated
Corrected July 25, 2024
July 10, 2024
Standard
Provide enough food/fluids to maintain a resident's health.
Quality of Life and Care Deficiencies · Tag F0692
G
Actual harm, isolated
Corrected July 25, 2024
July 10, 2024
Standard
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Quality of Life and Care Deficiencies · Tag F0686
G
Actual harm, isolated
Corrected July 25, 2024
July 10, 2024
Standard
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Nutrition and Dietary Deficiencies · Tag F0803
F
Potential harm, widespread
Corrected July 25, 2024
July 10, 2024
Standard
Provide care and assistance to perform activities of daily living for any resident who is unable.
Quality of Life and Care Deficiencies · Tag F0677
E
Potential harm, pattern
Corrected July 25, 2024
July 10, 2024
Standard
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Infection Control Deficiencies · Tag F0887
E
Potential harm, pattern
Corrected July 25, 2024
July 10, 2024
Standard
Provide and implement an infection prevention and control program.
Infection Control Deficiencies · Tag F0880
E
Potential harm, pattern
Corrected July 29, 2024
July 10, 2024
Standard
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies · Tag F0689
D
Potential harm, isolated
Corrected July 25, 2024
July 10, 2024
Standard
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Infection Control Deficiencies · Tag F0883
D
Potential harm, isolated
Corrected July 25, 2024
July 10, 2024
Standard
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Pharmacy Service Deficiencies · Tag F0761
D
Potential harm, isolated
Corrected July 25, 2024
July 10, 2024
Standard
Ensure medication error rates are not 5 percent or greater.
Pharmacy Service Deficiencies · Tag F0759
D
Potential harm, isolated
Corrected July 25, 2024
July 10, 2024
Standard
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Quality of Life and Care Deficiencies · Tag F0690
D
Potential harm, isolated
Corrected July 25, 2024
July 10, 2024
Standard
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Quality of Life and Care Deficiencies · Tag F0688
D
Potential harm, isolated
Corrected July 25, 2024
June 10, 2024
Complaint
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Quality of Life and Care Deficiencies · Tag F0740
D
Potential harm, isolated
Corrected June 20, 2024
June 10, 2024
Complaint
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Freedom from Abuse, Neglect, and Exploitation Deficiencies · Tag F0600
D
Potential harm, isolated
Corrected June 20, 2024
June 10, 2024
Complaint
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Resident Rights Deficiencies · Tag F0580
D
Potential harm, isolated
Corrected June 20, 2024
January 31, 2024
Complaint
Provide care and assistance to perform activities of daily living for any resident who is unable.
Quality of Life and Care Deficiencies · Tag F0677
D
Potential harm, isolated
Corrected February 7, 2024
October 31, 2023
Complaint
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Nutrition and Dietary Deficiencies · Tag F0812
F
Potential harm, widespread
Corrected November 3, 2023
October 11, 2023
Complaint
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Quality of Life and Care Deficiencies · Tag F0684
D
Potential harm, isolated
Corrected October 20, 2023
October 11, 2023
Complaint
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Resident Rights Deficiencies · Tag F0584
D
Potential harm, isolated
Corrected October 20, 2023
June 13, 2023
Fire safety
Provide family notifications of emergency plan.
Emergency Preparedness Deficiencies · Tag E0035
F
Potential harm, widespread
Corrected June 30, 2023
June 13, 2023
Fire safety
Establish roles under a Waiver declared by secretary.
Emergency Preparedness Deficiencies · Tag E0026
F
Potential harm, widespread
Corrected June 30, 2023
June 13, 2023
Standard
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Pharmacy Service Deficiencies · Tag F0755
F
Potential harm, widespread
Corrected June 27, 2023
June 13, 2023
Standard
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Quality of Life and Care Deficiencies · Tag F0698
D
Potential harm, isolated
Corrected June 27, 2023
June 13, 2023
Standard
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Quality of Life and Care Deficiencies · Tag F0690
D
Potential harm, isolated
Corrected June 27, 2023
June 13, 2023
Standard
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Quality of Life and Care Deficiencies · Tag F0684
D
Potential harm, isolated
Corrected June 27, 2023
June 13, 2023
Standard
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Resident Rights Deficiencies · Tag F0580
D
Potential harm, isolated
Corrected June 27, 2023
June 13, 2023
Standard
Provide and implement an infection prevention and control program.
Infection Control Deficiencies · Tag F0880
D
Potential harm, isolated
Corrected June 27, 2023

Severity letters follow the CMS scope-and-severity grid: A–C no actual harm with potential for minimal harm; D–F potential for more than minimal harm; G–I actual harm; J–L immediate jeopardy to resident health or safety. How to read inspection citations.

Fines and payment denials

CMS reports 1 federal penalty in the past three years, including $21,212 in fines.

DatePenaltyAmount / length
July 10, 2024Fine$21,212

Owners and managers

Individuals and organizations reported to CMS as owning or operating this nursing home.

NameRoleShareSince
KOHEN, TSIPPORAH
Individual
5% or greater direct ownership interest5%06/30/2017
AARON, JONATHAN
Individual
adp of the snfNOT APPLICABLE01/06/2025
MICHALSEN, THOMAS
Individual
adp of the snfNOT APPLICABLE03/10/2025
RHOE, MICHAEL
Individual
adp of the snfNOT APPLICABLE12/14/2020
RIPSTEIN, KENNETH
Individual
adp of the snfNOT APPLICABLE01/06/2025
RIPSTEIN, KENNETH
Individual
corporate officerNOT APPLICABLE06/30/2017
AARON, JONATHAN
Individual
operational/managerial controlNOT APPLICABLE01/06/2025
GRAF, MARCELLA
Individual
operational/managerial controlNOT APPLICABLE06/30/2017
MICHALSEN, THOMAS
Individual
operational/managerial controlNOT APPLICABLE03/10/2025
RHOE, MICHAEL
Individual
operational/managerial controlNOT APPLICABLE12/31/1999
RIPSTEIN, KENNETH
Individual
operational/managerial controlNOT APPLICABLE06/30/2017

Other nursing homes near Pa Peterson at the Citadel

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    ★★★★★1Much below average
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  4. Rock River Health Care

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  5. Fairhaven Christian Ret Center

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Frequently asked questions

What is Pa Peterson at the Citadel's rating?

Pa Peterson at the Citadel has 1 out of 5 stars on the CMS overall star rating. The average for Illinois nursing homes is 2.5 stars.

How many inspection citations did Pa Peterson at the Citadel receive?

Its most recent standard health inspection found 19 citations, compared with a Illinois average of 12.5. Every citation is listed on this page with its severity.

Does Pa Peterson at the Citadel accept Medicare and Medicaid?

CMS lists it as certified for: Medicare and Medicaid. Call the facility to confirm bed availability and whether it accepts your specific plan.

Who owns Pa Peterson at the Citadel?

It is for profit - partnership and part of Citadel Healthcare. The ownership section on this page lists the owners and managers reported to CMS.

Where is Pa Peterson at the Citadel and how do I contact it?

Pa Peterson at the Citadel is at 1311 Parkview Avenue, Rockford, IL 61107. Phone: (815) 399-8832.

About this data

Ratings and measures come from the Centers for Medicare & Medicaid Services (CMS), Medicare Care Compare. They're based on state inspections, patient surveys and facility reports, and they describe the past. Facilities change, so visit in person and confirm details directly. About our data · Spotted an error? Let us know.